Texas Pre Authorization Request Form PDF Details

In the heart of Texas, navigating the healthcare system and ensuring the necessary medications are covered can be a daunting process for both healthcare providers and patients alike. The Texas Pre Authorization Request form serves as a crucial tool within this landscape, specifically designed for Texas Medicaid, to streamline the approval process for certain medications not typically covered under standard pharmacy benefits. This comprehensive document requires detailed information about the patient—including their Medicaid coverage details, diagnosis, and the prescribed medication, alongside the physician's contact information. It also poses a series of questions aimed at determining whether the medication is being used within its FDA-approved indications, if it's supported by authoritative medical compendia, or if there's a history of the patient's intolerance or failure to respond to preferred medications. This process is not just a formality but a critical step in ensuring patients receive the most appropriate and cost-effective treatment. By stipulating that all submissions be faxed to Caremark with a secure location compliance as per HIPAA regulations, it underscores the care taken to protect patient information. Moreover, it highlights an ongoing commitment to making healthcare accessible while maintaining rigorous standards for treatment validation and patient privacy. Physicians are reminded at the end of the form to verify the truthfulness and accuracy of the information provided, cementing the responsibility of healthcare providers in the integrity of this process.

QuestionAnswer
Form NameTexas Pre Authorization Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesamerigroup texas prior authorization form, amerigroup precertification form, amerigroup medication prior authorization form, printable amerigroup forms

Form Preview Example

Prior Authorization Form for Texas Medicaid

Global Prescription Exceptions (Medicaid)

This fax machine is located in a secure location as required by HIPAA regulations.

Complete/review information, sign and date. Fax signed forms to Caremark at 1‐866‐255‐7569.

Please contact Caremark at 1‐877‐440‐3621 with questions regarding the prior authorization process.

When conditions are met, we will authorize the coverage of Global Prescription Exceptions.

Drug Name:

Patient Name:

Patient ID:

Patient Group Number: Patient Date of Birth:

Physician Name:

Physician Phone:

Physician Fax:

Physician Address: City, State ZIP:

Patient Information

Prescribing Physician

Diagnosis:

 

ICD Code:

Please circle the appropriate answer for each question.

1.

If this is an office‐administered injectable drug…

 

 

 

A. Is your intent to provide and bill for this medication? OR

Y

N

 

B. Is your intent to have it provided through a pharmacy?

Y

N

 

 

 

 

 

 

2.

Is the requested drug being used for an FDA‐approved indication?

Y

N

 

[If the answer to this question is yes, then skip to Question 4.]

 

 

 

 

 

 

3.Is the requested drug being used for an indication that is supported by information from

the appropriate compendia of current literature (e.g., AHFS, Micromedex, current

Y

N

accepted guidelines, etc.)?

 

 

 

 

 

4. Has the patient demonstrated a failure of or intolerance to a majority (not more than three)

Y

N

of the preferred formulary or preferred drug list alternatives for the given diagnosis?

 

 

5.Is the drug being prescribed within the manufacturer's published dosing guidelines, or

does it fall within dosing guidelines found in the compendia of current literature (e.g.,

Y

N

package insert, AHFS, Micromedex, current accepted guidelines, etc.)?

 

 

 

 

 

6. Is the drug being prescribed for a medically accepted indication that is recognized as a

Y

N

covered benefit by the applicable health plan's program?

 

 

Comments:

I affirm that the information given on this form is true and accurate as of this date.

Prescriber (or authorized) Signature and Date

PF‐TX‐0003‐12

March 2012

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